Comparison of Quality of Life Following Single- Event Multilevel Surgery (SEMLS) Using Bandaging and Casting Immobilization Methods in Cerebral Palsy Children

Objective Cerebral palsy (CP) is a non-progressive Neurodevelopmental disorder mainly treated using Single-event multilevel surgery (SEMLS). SEMLS contains using a casting method to immobilize the operated limb. However, in the present study, in addition to casting, the bandaging method was also applied. Bandaging is a newer method compared to casting. No study has used bandage for post-surgery immobilization. According to the best knowledge of the authors, no study has compared the outcome of bandage and cast for postoperative immobilization regarding the rehabilitation and quality of life (QoL) in the first and third months following the surgery, within the recovery period, which is associated with consequences like caring, hygiene, transferring, and mobility that affect the spirit and function of children. As a result, we decided to investigate the effect of these methods on the QoL of children the following surgery to treat CP. Materials & Methods Following an analytical cross-sectional design, 100 children (aged 4-12 years) were randomly divided into hemiplegic and diplegic CP. The Cerebral Palsy QoL questionnaire (CP QOL-Child) was filled by parents of the participants. Based on the type of administered immobilizer, 80 children were randomly divided into two groups (40 subjects in each group). All subjects were evaluated using a similar questionnaire in the first and third months after surgery. The non-parametric Mann-Whitney test and ANOVA test were used to compare the study groups. Results The mean ratio of QoL changes, based on the CP QoL-Child questionnaire, was significantly increased in the bandage group during the first month after surgery. However, for the cast group, this parameter was significantly decreased (P<0.001). In the third month after surgery, the mean ratio of QoL changes was significantly increased in both groups, but the difference in the mean ratio of QoL changes between the two methods wasn’t significant (P=0.64). Conclusion In the first month after surgery, the bandaging method was more effective than the casting method, but in the third month, the outcomes were similar for both groups.


Introduction
. In Iran, a prevalence of 2 per 1000 children is reported (8).
Currently available therapeutic options for CP include medical interventions, rehabilitation therapies, and complex orthopedic interventions.
Also, orthopedic surgeries are often used along with other treatments in order to prevent or correct secondary musculoskeletal problems in children with CP (9). The Single-Event Multilevel Surgery (SEMLS) approach is an effective strategy that comprises lengthening, transfer, and correction of deformities in one surgical session (10). SEMLS surgery is associated with reduced length of hospital stay, improved gait pattern, enhanced range of motion of joint, changes in the X-ray Iran J Child Neurol. Summer 2021 Vol. 15 No. 3 results, increased energy conservation as well as improved functional outcome (11)(12)(13)(14)(15)(16)(17).
Children with CP who had SEMLS surgery not only will experience better motor function but also will have improved quality of life (QoL) (18). In this type of surgery, the casting method is generally used for postoperative immobilization, but in the current study, the bandaging method was applied in addition to the casting (19). Lubicky et al. (2003), in a study intended to compare the casting method with a non-casting method, reported that the former resulted in more skin sores, wound infection, re-operation, and re-hospitalization rate than the latter. However, the difference was not statistically significant. It worth noting that they didn't declare another method of immobilization.
Apart from its ease of administration, casting promotes the healing process of osteotomies, prevents instrumentation failure, and protects the operated leg from injury. Meanwhile, it has some particular consequences like poor hygiene, bone pain following cast removal, scarring, and stiffness of joints, mainly as a result of immobilization (20).
In this study, the SEMLS surgery was performed in diplegic and hemiplegic CP children, preferably not older than 4 years, and the bandage was is considered in previous studies to evaluate the QoL of children has been nine months. However, two time points of one and three months after the surgery were considered. In fact, the study was performed in the recovery period, which is accompanied by some common problems like caring, hygiene, transferring, and mobility, which in turn affect both the spirit and daily function of children. Participants were selected from a population of individuals with CP referred to the orthopedic department of Akhtar hospital. All subjects were evaluated by a team of surgical specialties, and the goniometric measurements were also performed.

Materials & Methods
In the present study, the objectives of the study were explained to the parents of eligible children, and parental informed consent was obtained for all cases. In addition, medical ethics principles were followed, and no financial burden was imposed on participants due to participating in the study.

Results
Demographic characteristic of participants is presented in Table 1.
Central indicators and dispersion of QoL scores, separated by the study group, following the postoperative immobilization is provided in Table   2.
In the bandage group, the difference in mean QoL score before the surgery and the first month after the surgery was 0.76, which was not statistically significant (p=0.053). For the bandage group, this score was 2.6 three months after surgery. Also, the difference in mean QoL scores at the first month and at the third month after surgery was -1.21 and 1.74, respectively, which was statistically significant p<0.001). Furthermore, there was no significant difference concerning the mean QoL score between the two groups before the surgery (p=0.044). In addition, for both groups, the difference in mean ratio of QoL changes, based on the CP QoL-Child questionnaire, was significant in the first month after the surgery (P<0.00). We found an increase in mean ratio changes of QoL in the bandage group was observed (p<001); but in the cast group, it was -2.86% (chart 1). Furthermore, in the casting group, the postoperative mean ratio change of QoL was decreased significantly (p<0.001).
The mean ratio of QoL score changes three months after surgery compared to before surgery is provided in Chart 2. The mean ratio of QoL score changes in the third month after surgery in the bandage and cast groups was increased by 5.83 and 5.06%, respectively. This increase was statistically significant (p<0.001), but the difference in the mean ratio of QoL score changes between the two groups was not significant (p=0.64).

In Conclusion
In this study, two types of postoperative  However, this study highlighted significant changes in the mean ratio of the QoL score following administration of both casting and bandaging methods after surgery (p<0.001).